Clinical Psychology Adversely Criticized
- Author:
Sylvester, Ph.D.
University of Iowa.
From visits to a number of clinics and other places where mental retardation or deficiency is receiving attention, from interviews with physicians and psychologists who are not working in the field, and from current journals and newspapers, criticisms have been gathered of clinical psychology in its present status. The adverse criticisms may be reduced to the following:?(1) Mental tests are being overemphasized. (2) Clinical psychology is too much limited to diagnosis. (3) The work is not of much practical value, for little can be done to improve the mentality of the retarded and the defective. (4) Clinical psychology is usually based on the wrong kind of psychology. (5) The field should be cared for by the medical profession.
With very few exceptions, clinical psychologists must plead guilty to the charge of over-emphasizing mental tests. Much effort is being directed toward devising, refining, and standardizing testing devices with the apparent purpose of making them automatically measure intelligence in finely calibrated units. The futility of attempting this beyond certain limits is obvious when one remembers that psychology has not yet worked out all of the principles underlying the tests, and that standards of normal mentality are vague and indefinite. The Binet scale, the form board, and many of the tests adapted from the experimental laboratory are of great value in the clinic, but some of the effort spent in attempting to perfect and refine them is wasted. By giving more attention to the subjective study of children, examiners could reach a higher efficiency and make better diagnoses.
This over-emphasis on tests and mental measurements is due to reasons which may be enumerated as follows:?(a) Most psychologists have worked considerably in laboratory psychology, so they find in tests an adaptation of the methods and procedure in which they have been trained. (6) The inexperienced examiner has to depend on tests because he is not skilled in the interpretation of his direct observations of the child, (c) The experienced examiner can make the best use of assistants by having much of their work with his cases reported in terms of test results, id) In case records, test results are especially valuable, and for the comparison of individuals with the normal they are a necessity, (e) Because most tests yield quantitative results, they offer an attractive field for research. (f) People who bring children to be examined are best satisfied with diagnoses which are corroborated by the results of tests. (g) Educators, applied sociologists, and those of the general public who are interested, seem to expect the clinical psychologist to state his results in terms of tests and measurements. These are causes for the o eremphasis of tests but certainly they do not fully justify it. Considering them in order, it must be said of the first that the examiner who relies on tests in the clinic as he would in laboratory experimentation evidently forgets that results from the latter are usually rounded out by introspection which cannot be secured from a child. As to the necessity for the inexperienced examiner’s depending on tests, he must free himself from this dependence as quickly as possible, and he must take care that his interest does not become centered in the tests instead of in the child. To reasons (c) and (d), there can be no objections, for tests made by assistants economize the examiner’s time and help him to understand the case, and at the same time they give quantitative material for permanent records and for comparison with normal standards. In regard to their claim upon research, tests are worthy of the most serious studies, provided the investigators set their goal beyond mere measurement and standardization. Certain parts of the field will undoubtedly have to be worked in a not too intensive way before research can get a proper grasp on the more fundamental problems of diagnosis. The expectation of parents and others that mental diagnosis be made by means of devices as exact as an acid test, in some cases justifies an attempt to express conclusions in terms of test results. But the examiner himself must constantly remember that most tests are functional tests, and as such they deal with complexes that are only partially analyzable. Physicians rely comparatively little on functional tests.1 The nearest approach to testing functional capacity would be by means of an extensive and well balanced team of tests, but no scheme approximating completeness has been proposed.2 However, the single tests and teams of tests which have been devised are of great value. The caution is against over-reliance upon them. The second of the criticisms enumerated is that clinical psychologists fail to go beyond diagnosis. With this criticism is usually included the query, “Of what value would a physician’s services be if he merely diagnosed your case without treating it?” This usually comes from persons who have casually visited a clinic or read of the work. They have the notion that cases are merely examined and disposed of by an opinion expressed in the form of a diagnosis. In caring for either the physically or the mentally ill, the important thing of course is to know what is the matter with them. Treatment depends on diagnosis and often is the easier problem.
It is unfortunate that some psychologists do not concern themselves with treatment. An extreme instance recently came to my notice. A mother at considerable expense and effort took her child to a specialist in mental defects of children. He made a careful examination and gave his diagnosis, but when asked for advice as to what to do for the child he stated flatly that he did not allow himself to intrude into the field of therapeutics. It must be admitted that clinical psychology is in some ways back where medicine was about fifty years ago. The story is told of a Scotch physician of that time who after showing a visitor through his hospital said, “We diagnose, and diagnose, and diagnose.” “And,” inquired the visitor, “after that?” “We confirm our diagnosis.” Every diagnosis is more or less a prognosis, and stating that a child is retarded because of physical condition or of faulty school management is telling what must be changed in order to remedy the defect. Most psychological clinics go as far into treatment as they can, giving suggestions and directions which are as truly perscriptions as are those which the physician gives to his patient to have filled by the druggist. The great majority of cases are requested to return for re-examination after the prescribed treatment has been applied, some of them reporting many times and continuing pedagogical and other treatment under direction for months. On October 1, 1912, 228 of the 482 cases handled by the Psychological Clinic of the University of Pennsylvania during the previous twelve months were still under observation. A few of them had been carried for more than a year. In addition the Clinic had in residence at schools from six to eight children who were being studied and taught. The report for the present year will show even more extended directing and following up of cases. Certainly this clinic is doing much more than diagnosis, and some others are working on the same plan. More therapeutics is desirable, but clinical psychology should be given credit for having done remarkably well in this direction considering the short time it has been in the field.
Another criticism from those not fully acquainted with what is being done, is that clinical psychology is neither practical nor necessary; that medical treatment does all that can be done for retarded and defective children. For those who raise this point, the concept of retarded children includes only children who have adenoids, faulty vision, or other purely physical defect, and their notion of defectives includes only unimprovable imbeciles and idiots. They fail to recognize the great number of cases where there is some peculiarity which causes ordinary school methods to go awry or home and school training to fail, or where there is a remediable bad habit or learning attitude. After the case has been analyzed and the defect or peculiarity discovered, these children can often be restored to normal condition with surprising rapidity. Where the defect is an incurable one, its identification may make possible the building up of other capacities which render it less conspicuous. Even the cases sent to institutions for the feeble minded are not entirely hopeless. When the kind of work that Dr Fernald is carrying on at Waverly becomes more general, the pessimistic attitude toward this field will be modified. Through his effective use of Seguin devices the children are introduced into industrial work and made efficient to a degree that one would believe them by no means capable of attaining. Progress will perhaps lead to specialized institutions such as the one which Berlin is to have for a psychopathic type of children.3 Psychology and pedagogy have before them a work of much promise with these trainable defectives who are remediably retarded, and the work has already been well begun. Of the five criticisms discussed in this paper, the one on the impracticability of clinical psychology is the least valid.
Psychology as a science follows for the most part the rule of proceeding from the known to the unknown. In regular university courses emphasis is placed on the simpler mental processes with experimentation on those which are the most tangible, while study of the more complex and vague processes tends to go little beyond where it can be anchored to establish facts. The fourth of the criticisms against clinical psychology objects to its being so largely based on this kind of general psychology. Those who raise the objection do not approach the subject from the laboratory angle. One group takes its view-point from the psychology of Freud, Bleuler, and Jung which postulates a subconscious and attempts to build up a psychology largely from mental pathology. Another group does not accept Freud or the subconscious (subterranean psychology, as Dr Lloyd, one of this latter group, has wittily dubbed it), but they believe that much of laboratory psychology is impractical and they choose to approach mental pathology directly, handling it in terms of its own manifestations. Dr Burr has stated it in rather radical terms, “I have not yet been convinced that the study of formal psychology throws any light on psychiatry.”4 A part of the present difficulty lies in the exaggerated notion of the differences among these view-points. Most examiners who follow the orthodox laboratory psychology do not believe in a subconscious, but in examining certain peculiar types of children they use methods of analysis involving much of the Freudian procedure. And they do not take time to drag in so much of formal psychology and laboratory procedure as is generally supposed. Likewise, the psycho-analysists would not presume to explain mere dulness and stupidity in terms of dissociations, repressions, and conflicts. The three view-points are not mutually exclusive in practical work at present, but most examiners confine themselves too narrowly to one of them. It is likely that the most serviceable psychology in the clinic is that which builds upon scientific facts experimentally demonstrable, and which also takes cognizance of the necessity of working in realms which laboratory procedure does not enter, and deriving all the help it can from Freudian and direct pathological methods. The examiner whose training has been largely in the experimental laboratory will do well to read some of the articles written from other view-points. The last of the five objections holds that mental retardation and deficiency in children should be treated by the medical profession. At present few physicians are prepared for this work. Their medical school training has scarcely touched it,5 and the field is of small extent as compared with their general practice of medicine. Obviously the work must be attended to by specialists, and the real question is as to whether the best specialist has given his major attention to medicine or to psychology. The opinion of many physicians is expressed in a recent article in which the employment of a consulting psychologist in a hospital for the insane calls forth the exclamation, “Could anything be more monstrous or preposterous?”6 Is it any the less unthinkable for one who knows little of psychology to deal with mental deviation? Ignorance of the subject causes many physicians to minimize its difficulties. For instance a writer states with assurance that Binet tests are unnecessary because “feeblemindedness is so easily detected.”
Of course the clinical psychologist who has not a medical education cannot work alone. He must work in cooperation with medical clinics which attend to the physical examinations and treatments. Whether the future specialist in mental retardation and deficiency in children must have completed courses in pedagogy, psychology, and medicine, or whether he can make himself more efficient by specializing in a limited field, is a question still to be decided. In general the medical profession is giving the psychologist every chance to prove his worth. Surgery and dentistry have come to be dignified professions. Even the reliable chiropodist is welcomed because he does a work which “medical practice has always assumed was beneath its dignity, so left to anybody and everybody.”7 Certainly the psychologist will in time be fully endorsed if he proves that he can be entrusted with duties for which the physician has not time adequately to prepare.
Were it within the scope of this paper, a list of favorable observations on clinical psychology could be given, which would be far more impressive than these five adverse criticisms. Suffice it to say that steady progress is being made both in the amount of work done and in its quality. Although psychological examination of school children has extended rapidly, the demand for it is more urgent than ever.8 London has recently appointed a director of clinical psychology for the city schools. Psychological examinations in connection with juvenile courts are well established, and consulting psychologists seem to be rendering valuable service in hospitals for the insane. Another call for applied psychology comes from penal institutions. An Indiana reformatory has recently called from a university a professor of psychology, and other reformatories in the east have employed psychologists for some time. As yet we have only a vague notion as to how many criminals are mentally defective, and examiners will have to attain considerably higher skill before an estimate of the approximate number can be made. There is of late a general interest in the problem of the defectives who are mingling in society. An Australian physician observes, “A lot of our street loafers are defectives,”9 and he urges that this dangerous element in society be not neglected. At the present moment there is an insistent call for better psychological examinations at immigrant stations. Those who are attempting to do the work are asking for better facilities and more help. Dr Knox calls attention to the difficulties of detecting morons, and to the fact that examiners must have rather definite notions of the normal Italian, Greek, or Pole, in order to recognize the defectives.10
Dr Knight mentions several difficulties, especially the shortness of the examinations and the confused state of mind in which one finds the immigrants.11 Dr Wilson shows still further how much a normal foreigner may differ from our ordinary concept of normality, and he shows the serious limitations of our tests.12 Dr Goddard’s results from testing a few immigrants indicate the possibilities of the work.13 Some of the medical journals have been carrying on propaganda through editorials against feebleminded immigrants. It is shown that a large percentage of the children in the special backward classes of the New York Public Schools are foreign born or of foreign parentage, and that the number of aliens who find their way into institutions for the neuropathic, the feebleminded, and the insane is very great. The New York Chamber of Commerce last year transmitted to Congress a resolution asking that taxpayers be protected against the importation of the feebleminded. These calls for applied psychology are of interest, because they have been evoked largely by the visible results of what has been accomplished through the application of psychology to retarded and defective children. There is convincing evidence that clinical psychology is worth while, and there is every assurance that the objections urged against it can be satisfactorily met.
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